Perspectives
Book
Leo Kanner, Hans Asperger, and the discovery of autism
Steve Silberman discovered a
well-kept secret about autism. In his
stunning big book NeuroTribes (big
in size at more than 500 pages, and
big in vision, spanning the history of
autism from the late 19th century
to the present day), he imparts the
secret, drip-feeding it through a
remarkable narrative, in one of the
most fascinating accounts of autism
I have ever read. At one level, this
is a who-done-it, in keeping with
Silberman’s profession of investigative
journalist. He digs into the detail of
people’s lives, and uncovers the secret
that one scientist tried to hide.
As everyone in the autism
community knows, child psychiatrist
Leo Kanner at Johns Hopkins University
School of Medicine in Baltimore, MD,
USA, wrote a seminal article in 1943
in which he described—“for the first
time”—11 children in his clinic without
the social instinct to orient towards
other people, who were mostly
focused or even obsessed with objects,
and who had a “need for sameness”
or a “resistance to (unexpected)
change”. To give a name to this new
psychiatric condition, Kanner coined
the term “infantile autism”. Kanner’s
article made medical history, as
befits someone who discovers a new
medical condition. But just 1 year
later, paediatrician Hans Asperger, at
the University of Vienna in Austria,
wrote an article describing a group of
children in his clinic who shared many
of the same features. Kanner’s paper
became highly cited and high profile,
whereas Asperger’s article went
almost unnoticed.
For almost 40 years, the English-
speaking autism community knew
almost nothing about Asperger’s
article. Then, in 1981, child psychiatrist
Lorna Wing at the UK’s Institute of
Psychiatry in London published an
article that brought it to the world’s
attention. The autism community
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assumed that the reason Asperger’s
article had languished in the shadows
was because it was written in German.
And for the past 35 years since
Wing’s article, the autism community
assumed that, since Kanner claimed he
had no awareness of Asperger’s work,
this was just one of those strange
cases of two scientists independently
discovering the same medical
condition, coincidentally within a year
of each other. Enter Silberman, whose
job as a journalist is to dig deeper, to
check the truth of our assumptions.
“In science, as in commerce, or
exploring space, being there
first is important, and Silberman
sees the real importance of what
he has stumbled upon.”
Silberman goes back in time, to
peek into the clinics of Kanner and
Asperger separately, to see what they
were up to. He discovers Asperger to
be a modest, unassuming man, half a
century ahead of his time in designing
a school for the children he saw that
suited their differently wired cognitive
style, playing to their strengths rather
than focusing on their difficulties.
Silberman finds that Asperger’s group
of patients were diverse, ranging from
one child who was mute to another
child who was articulate to the point
of pedantry, from the boy who flapped
his hands repetitively to the child
who obsessively collected minutiae
about astronomy. Asperger coined
a name for his group of patients:
autistic psychopathy.
Asperger described his patients
across a wide age range, and how their
social and obsessive characteristics
blur into what, outside the clinic
setting, would simply be described
as eccentricity or expertise. Although
Asperger saw this wide range of
individuals—what today would be
called the “autism spectrum”—he
placed special emphasis on those he
likened to “absent-minded professors”,
who showed precocious interest
in systems and how things work,
despite their social awkwardness and
difficulties in social understanding.
Silberman discovers that Asperger was
lecturing about these children as early
as 1938, some 5 years before Kanner’s
announcement of the “discovery” of
autism. In science, as in commerce,
or exploring space, being there first
is important, and Silberman sees NeuroTribes: The Legacy of
the real importance of what he has Autism and How to Think
Smarter about People who
stumbled upon. Think Differently
Silberman is open-minded and Steve Silberman.
hoped to find that Kanner’s failure Allan and Unwin, 2015.
Pp 544. £16·99
to cite Asperger’s work in his 1943 ISBN 9781760113636
article was simply ignorance, not
intellectual theft. As Silberman travels
back in time and enters Kanner’s
clinic, he catalogues the many positive
contributions that Kanner made,
including how he helped nearly
200 Jewish refugee doctors flee to
the USA from the Holocaust, and
how Kanner humanised American
psychiatric institutions. But Silberman
also finds something altogether more
disturbing: a man who was desperate
to make his name in the history
of medicine, and who seemed to
have been willing to do some rather
underhand things to achieve this goal.
Far from finding Kanner to be
a man who was unaware that
some 4000 miles away in Vienna,
struggling under Nazi occupation,
a fellow physician had described a
similar group of patients, Silberman
unearths evidence that Kanner must
have known about Asperger’s work.
How? Because Georg Frankl, the chief
diagnostician in Asperger’s clinic
in 1938, came to Johns Hopkins
University to work in Kanner’s clinic
later that year. Long before the
internet or email, the transmission
of scientific ideas could nevertheless
flow from one lab to another through
1329
 Perspectives
Wellcome Library, London
Henry Cavendish (1731–1810), aquatint by C Rosenberg after W Alexander
a doctor working in both. Frankl had
crossed the Atlantic and Silberman’s
argument is that Kanner heard about
these special children in Vienna, found
some similar ones in his Baltimore
clinic, and repackaged them as his
own discovery.
Intellectual theft—if true—is a serious
allegation, but Silberman identifies
some additional acts that Kanner was
also guilty of. One was stating that
the parents of children with autism
were cold and unemotional types, and
that in the heyday of psychoanalysis
engaging in parent-blaming, Kanner
blamed parents for causing their
child’s autism. Although he covered
himself by also inserting the word
“inborn” in his 1943 paper, Kanner
promoted the idea of toxic parenting
being a cause of autism. In the history
of autism we tend to think that
psychologist Bruno Bettelheim was
1330
the originator of this unfair, unkind,
and groundless “psychogenic” theory
that led to “parentectomy”, with
parents—particularly mothers—being
discouraged from visiting their child
in residential school. But it seems that
Bettelheim was just a high-profile
exponent of Kanner’s original
“refrigerator parent” idea.
Silberman identifies other acts that
Kanner was responsible for, which
he argues set the field back decades.
First, Kanner insisted that autism
was a condition of infancy, putting
the spotlight on early childhood and
rendering adolescents and adults
with these traits invisible, so keen
was he to establish the new field
of child psychiatry. Second, Kanner
insisted that autism was rare, giving
rise to the myth that the prevalence
was four in 10 000 people, even
though in London during the 1970s
Lorna Wing and Judy Gould had
already found it was between four and
five times more common than this.
Third, Kanner insisted that autism was
a well-delineated narrow category,
even though others were finding the
category had blurred edges and was
more of a spectrum. Asperger made
none of these mistakes. The effect
of Kanner’s dogmas was to leave
those with Asperger’s syndrome—
this “neurotribe”—out in the cold,
unknown and unnoticed, for much
longer than needed to be the case.
Silberman is not the first to suggest
that Asperger’s work pre-dated
Kanner’s (Adam Feinstein makes a
similar point in his valuable book
A History of Autism: Conversations
with the Pioneers), but Silberman is
the first to have found the existence
of Frankl, the link between the two
scientists. Silberman’s dethroning
of Kanner is monumental in several
ways. First, Silberman portrays the
founding father of child psychiatry
as guilty of suppressing the truth
about his discovery, a little like how
James Watson and Francis Crick took
the credit for the discovery of the
double-helix structure of DNA without
acknowledging the contribution of
Rosalind Franklin. Second, Silberman
tells a story about a much wider set
of people on the autism spectrum
who were previously invisible under
Kanner’s rubric, and who Silberman
argues included those socially awkward
but technically talented individuals
who invented wireless communication
through hand-held radios, the
precursor to the internet, and who
included distinguished scientists
such as Henry Cavendish and Paul
Dirac, both in Cambridge. Silberman
describes how Cavendish showed all
the features of Asperger’s syndrome.
Cavendish was a genius at devising
extraordinarily precise methods to
answer hitherto intractable scientific
problems in the 1790s, such as
calculating the density of the Earth,
but he went to extreme methods to
avoid people. Third, Silberman paints
a portrait of a people who needed
a diagnosis, were overlooked and
excluded by the psychiatric profession
and their diagnostic handbook the
Diagnostic and Statistical Manual of
Mental Disorders, and so suffered
unnecessarily for decades.
Finally, in a style that could apply to
any civil rights liberation movement,
Silberman provides a voice for a
minority who think differently, those
overlooked millions of people on
the autism spectrum who, because
of Kanner’s insistence on a narrow
category in childhood, were denied
access to services and help. Silberman’s
book will be valued by many as telling
a triumphalist story after decades of
silencing, including the silencing of the
doctor who actually discovered autism.
NeuroTribes provides an alternative to
the medical or disease model of autism
and sits more comfortably with the
modern neurodiversity model, and is
ultimately a book that respects and
humanises those who are its focus.
Simon Baron-Cohen
Autism Research Centre, Cambridge
University, Cambridge CB2 8AH, UK
sb205@cam.ac.uk
www.thelancet.com Vol 386 October 3, 2015